Microsoft word - mi ortho health history child

CONFIDENTIAL CHILD ORTHODONTIC PATIENT QUESTIONNAIRE PATIENT INFORMATION: Patient’s Name: ____________________________________________________________________ Sex: M F Last First MI Preferred Name: _________________ Birth Date: ____________ Age____ Home Phone: (______)_________________
Address: _____________________________________________________ City: _______________________________
State: ________ Zip: _______________ Patient’s E-mail Address: ___________________________________________
Name of School: ___________________________________________________ Grade Level: ____________________
Hobbies/Interests: __________________________________________________________________________________
Why are you and your child seeking orthodontic treatment? (Please be as specific as possible): _____________________
________________________________________________________________________________________________
Who referred you to our office? _______________________________________________________________________
FAMILY STATUS:
Father: Mr./Dr.____________________________________________________ Home Phone: (_____)_______________
Address: ______________________________________ City: ____________________ State: ______ Zip:__________
Employer: ___________________________________________ Occupation: __________________________________
Work Phone: (______)_______________ E-Mail Address: _________________________________________________
Cell Phone: (______) _______________ What number would you prefer we use to contact you? ___________________
Mother: Mrs./Ms/Dr._________________________________________________ Home Phone: (______)______________
Address: ______________________________________ City: ____________________ State: ______ Zip:__________
Employer: ___________________________________________ Occupation: __________________________________
Work Phone: (______)_______________ E-Mail Address: _________________________________________________
Cell Phone: (______) _______________ What number would you prefer we use to contact you? ___________________
Marital status of parents: ___________ If divorced, who has custody? ___________ Is the patient adopted? __________
Names and birthdates of patient’s siblings: ______________________________________________________________
_________________________________________________________________________________________________
Responsible Party: Mr./Mrs./Ms./Dr.____________________________________ Home Phone: (_____)_______________
Relationship to Patient: ___________________________ If not a parent, do you have legal guardianship?: ___________
Address: ______________________________________ City: ____________________ State: ______ Zip:__________
Employer: ___________________________________________ Occupation: __________________________________
Work Phone: (______)_______________ E-Mail Address: _________________________________________________
Cell Phone: (______)__________________ What number would you prefer we use to contact you? ________________
INSURANCE INFORMATION: Will you be using dental insurance? ___Yes ___ No If yes, please provide the following:
Primary Subscriber: _____________________________________________ SS# _______________________________
Date of Birth: ______________________ Employer: ______________________________________________________
Insurance Company: ___________________________ Group # ________________ Telephone: (_____)_____________
Secondary Subscriber: ___________________________________________ SS# ______________________________
Date of Birth: ______________________ Employer: ______________________________________________________
Insurance Company: ___________________________ Group # ________________ Telephone: (_____)_____________
(QUESTIONNAIRE CONTINUES ON OTHER SIDE OF SHEET)DENTAL HISTORY:
Patient’s Dentist: _____________________________________________ Phone: (_______) ________________________________
Address: ____________________________________________________________________________________________________
Date of last dental examination and cleaning: _____________________ Drinking water in the home from: __ City __ Well __ Bottled
Has this patient ever had previous orthodontic treatment or a consultation?
No If yes, when? ________________________
Has another member of the family had orthodontic treatment?
No Who?________________________________________
MEDICAL HISTORY:
Family Physician: ________________________________________________ Phone: (_______) ______________________________
Address: ____________________________________________________________________________________________________
Is the patient currently under a physician’s care?
No If yes, please explain _______________________________________
Is the patient taking any medicine at this time?
No Specify: __________________________________________________
Is the patient currently taking (or has ever taken) any oral or IV bisphosphonate drug (eg. Actonel® (risedronate), Boniva® (ibandronate), Fosamax® (alendronate), Skelid® (tiludronate), Didronel® (etidronate), Aredia® (pamidronate), Zometa® (zolendronic acid), Bonefos® (clodronate)?
No If yes, reason: _________________________________________
Is the patient allergic to any medication?
No Specify: _____________________________________________________
Does the patient have any other allergies?
No Specify: _____________________________________________________
Does the patient have or has the patient ever had any of the following?
Bleeding Disorder Epilepsy/Seizures Injury to Head
Oral Ulcers Rheumatic Fever Speech Therapy Previous Surgery
**If the patient has a heart condition, please specify: ________________________________________________________________
Does the patient need to be premedicated (with antibiotics) for routine dental procedures? ___ Yes ___ No
If yes, reason: ________________________________________________________________________________________
Does the patient have any other disease, condition, or problem not listed above? Please explain: _____________________________
___________________________________________________________________________________________________________
Doctor’s Notes: ______________________________________________________________________________________________
___________________________________________________________________________________________________________
DOES/DID THE PATIENT:
No Brush his/her teeth: Often Occasionally Reluctantly
No If yes, at what age was the habit discontinued? _________________
PATIENT’S ATTITUDE TOWARD ORTHODONTIC TREATMENT:
The patient’s interest in having treatment is: Excited Willing if necessary Reluctant BEHAVIOR ASSESSMENT:
Personality (check all that apply): Calm Nervous Quiet Shy Outgoing Uncooperative Cooperative
Progress at school when compared to children of the same age: Behind Same level Advanced GROWTH STATUS: Females: Has the patient started her menstruation? Males: Has the patient undergone voice changes?
☺Thank you for your help! We’re excited to get to know you better…. ☺
Signature of the person completing this form:_____________________________________________________________
Relationship to the patient:_____________________________________________ Today’s date:___________________